Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Management type 2 DM with Insulin Workshop 1 and when to use or not to use Resources needed to do it properly The minimum Staff support who are trained Access to dietician and podiatrist Access to Nurse specialist team if needed Basic supplies to start and maintain insulin Knowledge of the equipment Know about glucagon Computer and relevant software Patient brochures Knowledge to do it properly Know your insulins and know the oral agents Know the delivery systems for insulin Work out patient (patho) physiology Get a correct classification of DM if possible Understand benefit and risk Recognise futility Big room… lots of people Participation essential Share experiences please Work stations set up for hands on Introduction Case: Mrs RS 54 years old School assistant; clerical; low responsibility Married; says one of the few positives in her life 3 children, all adult and overseas or elsewhere Diabetes 14 years Overweight all adult life now 112 kg, BMI: 39 General job/life dissatisfaction and hates being so fat Little exercise but tries and loses momentum Financially OK, no house mortgage Diabetes history Medication Metformin 1g bd Gliclazide 160 mg BD Pioglitazone 30 mg (3 years) Insulin 120 units glargine at 9pm (>1U/kg) for last year Blood glucose Glycaemia poorly controlled: A1c 9-10 % (75-85 mmol/mol) Recent evening preprandial BGLs average 11 mmol/L Recent evening postprandial BGLs average 15 mmol/L Significant other health factors; no other issues if not detailed Medications ACE plus CCB Statin Blood pressure usually <130 sBP LDL 2.1 mmol/l, HDL 1.0 mmol/l, Trigs 2.5 mmol/l with a glucose profile like this 20 INSULIN glargine 120 U 15 Plasma glucose (mmol/L) Plasma glucose (mmol/L) 20 15 10 10 5 5 Meal Meal Meal 0 0 06:00 10:00 14:00 18:00 22:00 02:00 06:00 What would you do and how? What resources would you need? Back to the case Mrs RS Using Very Metformin, Pio, SU, Insulin at high dose high HbA1c Mrs RS: what really happened Tried basal bolus finally after other insulin regimens failed No change in glucose parameters despite getting up to 200 U per day Piogliazone stopped; no benefit seen Roux-en Y Insulin fell to 40 Units per day single dose Felt much better, mood better.. More energy.. I feel alive Moved job, now CEO large firm ‘’should have done it years ago’ and maybe would not have needed insulin. What if…? She was 74 kg using 42 units And this is the Insulin profile And not 112 kg using 120 units With glucose profile like this 20 15 15 10 10 5 Plasma glucose (mmol/L) Plasma glucose (mmol/L) 20 5 Meal Meal Meal 0 0 06:00 10:00 14:00 18:00 22:00 02:00 06:00 What would you do and how? Basal bolus best 20 15 15 10 10 5 Plasma glucose (mmol/L) Plasma glucose (mmol/L) 20 5 Meal Meal Meal 0 0 06:00 10:00 14:00 18:00 22:00 02:00 06:00 More cases Case 1: 25 yr male with type 1 DM for 10 years going on o/s experience Using basal bolus insulin of Glargine (18 Units) and Humalog 4-6 Units pre meal usually, with corrections as needed. Generally holds A1c about 55-60 mmol/mol and no hypo issues. Seeks help as about to go overseas to Europe by self; wants to know how to manage insulin on flight Plane goes at 7pm to Auckland from CHCH then leaves to Los Angeles at 2130pm arriving 1500hrs on the same day in Los Angeles after 12 hour flight. 2 meals served, one at departure and 1 just prior to landing Transit in a closed room for 1 hour then boards again for another 11 hour evening flight to Heathrow. Departs at 1700 hrs and arrives 11am in London. Two meals again. Case 2; 67 year old women with Type 2 DM on metformin HbA1c usually 6.6% or 50 You diagnose PMR and start on Prednisone 40 mg am Glucose levels take off and go into double figures during the day Case 3: 40 years diabetes and using insulin for 20 years currently Humalog Mix 25 BD Doses are 28 U am and 40 U pm Case 4: 50 year old male, weight 71 kg On Humalog Mix 25 30 U am and 20 Units pm pre meals of breakfast and dinner for 1 year. Insulin resulted in much improved glucose levels and better energy. Using metformin as well Glycaemic regulation: Hb A1c 50 mmol/mol Evening insulin reduced over last few months because prone to hypos around 3 am; needed ambo only once in last year. Not keen on more injections Case 5: Called to see male patient aged 42 who has D and V’s Others in same situation in house. Can’t hold solids down but is having some oral fluid. Diarrhoea about 6 times per day Usual Insulin is Humalog mix 25: 30 U am and 30 Units pm Body weight is 63 kg On insulin since aged 36 yrs, and usually well regulated Case 6: spot diagnosis Case 7: female aged 62 and 94 kg Taxi driver doing shift work On Metformin and SU at max doses 12 years DM Glucose levels often double figures when tested. Has refused Insulin to date